Article Structure
The VA Form 21-0781A, known as the Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD) Secondary to Personal Assault, plays a crucial role for veterans seeking to establish a connection between their military service and PTSD resulting from traumatic incidents. This form is designed to gather detailed information about specific stressful events that occurred during service, which may have contributed to the veteran's current mental health condition. It requires veterans to document incidents with precision, including dates, locations, and descriptions, ensuring that the Department of Veterans Affairs (VA) can effectively research military records and other relevant sources. Additionally, the form prompts veterans to identify other potential sources of information, such as medical professionals or fellow service members, who may provide supporting statements. Completing this form accurately is essential, as it directly impacts the ability to obtain necessary benefits and support. Veterans are urged to approach this process with care and detail, as the information provided will be critical in validating their claims and accessing the resources they need.
Form Sample
OMB Approved No.
STATEMENT IN SUPPORT OF CLAIM FOR SERVICE CONNECTION FOR POST- TRAUMATIC STRESS DISORDER (PTSD) SECONDARY TO PERSONAL ASSAULT
IMPORTANT: If you or someone you know is in crisis, call the Veterans Crisis Line at 988 and then press 1, or visit https://www.veteranscrisisline.net/ to chat online, or send a text message to 838255 to receive confidential support 24 hours a day, 7 days a week, 365 days a year. Support for deaf and hard of hearing individuals is available.
INSTRUCTIONS: List the stressful incident or incidents that occurred in service that you feel contributed to your current condition. For each incident, provide a description of what happened, the date, the geographic location, your unit assignment and dates of assignment. Please complete the form in detail and be as specific as possible so that research of military records can be thoroughly conducted. For more information, you can contact VA online through Ask VA: https://ask.va.gov/ or call us
Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly and insert one letter per box to help expedite processing of the form.
1.VETERAN'S NAME (First, Middle Initial, Last)
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2. SOCIAL SECURITY NUMBER |
3. VA FILE NUMBER (If applicable) |
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4. DATE OF BIRTH (MM/DD/YYYY) |
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5. VETERAN'S SERVICE NUMBER (If applicable) |
6. TELEPHONE NUMBER (Include Area Code) |
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Enter International Phone Number (If applicable) |
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SECTION II: STRESSFUL INCIDENT(S)
8A. DATE FIRST INCIDENT OCCURRED |
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8B. DATES OF UNIT ASSIGNMENT (MM/DD/YYYY) |
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(MM/DD/YYYY) |
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8C. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)
8D. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION, CAVALRY, SHIP)
8E. DESCRIPTION OF THE INCIDENT
VA FORM |
SUPERSEDES VA FORM |
PAGE 1 |
|
JUN 2021 |
VETERAN'S SOCIAL SECURITY NO.
SECTION II: STRESSFUL INCIDENT(S) (Continued)
8E. DESCRIPTION OF INCIDENT (Continued)
9.OTHER SOURCES OF INFORMATION: Identify any other sources (military or
9A. NAME (First, Middle Initial, Last)
9B. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
City
State/Province
Country
ZIP Code/Postal Code
9C. NAME (First, Middle Initial, Last)
9D. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
City
State/Province
Country
ZIP Code/Postal Code
9E. NAME (First, Middle Initial, Last)
9F. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
City
State/Province
Country
ZIP Code/Postal Code
VA FORM |
PAGE 2 |
VETERAN'S SOCIAL SECURITY NO.
SECTION II: STRESSFUL INCIDENT(S) (Continued)
10.Please provide in the space below any other information that you feel is important for us to know that may help your claim. The following are some examples of behavioral changes that you may have experienced following the incident(s):
•visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment
•sudden requests for a change in occupational series or duty assignment
•increased use of leave without an apparent reason
•changes in performance and performance evaluations
•episodes of depression, panic attacks, or anxiety without an identifiable cause
•increased or decreased use of prescription medications
•increased use of
•substance abuse such as alcohol or drugs
•increased disregard for military or civilian authority
•obsessive behavior such as overeating or under eating
•pregnancy tests around the time of the incident
•tests for HIV or sexually transmitted diseases
•unexplained economic or social behavior changes
•breakup of a primary relationship
SECTION III: CERTIFICATION AND SIGNATURE
I HEREBY CERTIFY THAT the foregoing statement(s) are true and correct to the best of my knowledge and belief.
11. VETERAN'S SIGNATURE (REQUIRED)
12.DATE SIGNED (MM/DD/YYYY)
PENALTY: The law provides severe penalties which include fine or imprisonment or both, for the willful submission of any statement or evidence of a material fact, knowing it is false, or fraudulent acceptance of any payment to which you are not entitled.
PRIVACY ACT INFORMATION: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in VA system of records, 58VA21/22/28, Compensation, Pension, Education and Veteran Readiness and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. However, the requested information is necessary to obtain supporting evidence of stressful incidents in service. If the information is not furnished completely or accurately, VA will not be able to thoroughly research your military records and other sources for supporting evidence. The responses you submit are considered confidential (38 U.S.C. 5701).
RESPONDENT BURDEN: We need this information in order to assist you in supporting your claim for
VA FORM |
PAGE 3 |
Document Specifications
| Fact Name | Details |
|---|---|
| Form Purpose | This form is used to support claims for service connection for PTSD related to personal assault incidents during military service. |
| OMB Approval | The form has been approved by the Office of Management and Budget (OMB) under number 2900-0659. |
| Time to Complete | Respondents are estimated to take about 1 hour and 10 minutes to complete the form. |
| Governing Law | This form is governed by Title 38, United States Code, which pertains to veterans' benefits. |
Steps to Filling Out Va 21 0781A
Completing the VA Form 21-0781A is an essential step in supporting your claim for service connection related to post-traumatic stress disorder (PTSD). After gathering the necessary information, follow these steps to ensure the form is filled out accurately and completely.
- Obtain the form: Download the VA Form 21-0781A from the official VA website or request a hard copy from your local VA office.
- Section I - Veteran's Identification Information: Fill in your full name, social security number, VA file number (if applicable), date of birth, service number (if applicable), telephone number, and email address (optional).
- Section II - Stressful Incident(s): Start by documenting your first stressful incident. Enter the date it occurred, the dates of your unit assignment, the location of the incident, and your unit assignment during that time.
- Describe the incident: Provide a detailed description of what happened during the incident. Be as specific as possible to aid in the review of your claim.
- List other sources of information: Identify individuals or organizations that may have information about the incident. Include their names and mailing addresses in the designated sections.
- Provide additional information: If there are any other relevant details that may support your claim, such as behavioral changes after the incident, include that information in the space provided.
- Section III - Veteran Signature: Sign and date the form to certify that the information provided is true and correct to the best of your knowledge.
- Review: Before submitting, review the completed form for accuracy and completeness. Ensure all sections are filled out and legible.
- Submit the form: Send the completed form to the appropriate VA office as indicated in the submission instructions.
After submitting the form, you may want to follow up with the VA to confirm receipt and check the status of your claim. Ensure you keep copies of all documents for your records.
More About Va 21 0781A
What is the VA Form 21-0781A used for?
The VA Form 21-0781A, also known as the Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD) Secondary to Personal Assault, is used by veterans to document stressful incidents that occurred during military service. This form helps establish a connection between the veteran's current mental health condition and their service experiences.
Who should fill out the VA Form 21-0781A?
Veterans who believe they have PTSD related to personal assault during their military service should complete this form. It is specifically designed for those who have experienced stressful incidents that may have contributed to their current condition.
What information is required on the form?
The form requires detailed information about the stressful incidents, including descriptions of what happened, dates, locations, unit assignments, and any other sources of information that may support the claim. Veterans should be as specific as possible to aid in the research of military records.
How long does it take to complete the form?
It is estimated that completing the VA Form 21-0781A will take approximately 1 hour and 10 minutes. This includes reviewing the instructions, gathering necessary information, and filling out the form.
Can I submit the form online?
Yes, veterans can complete the VA Form 21-0781A online or by hand. If filling it out by hand, it is important to print the information clearly to ensure accurate processing.
What should I do if I need more space to provide information?
If additional space is needed, veterans can attach a separate sheet of paper. It is important to indicate which item number the additional information corresponds to on the form.
What if I have reported the incident to someone?
If the incident was reported to military or civilian authorities, or if the veteran sought help from a counseling facility, it is crucial to include this information on the form. Providing names and addresses of these sources can help the VA obtain supporting evidence for the claim.
What happens if I do not provide accurate information?
Providing incomplete or inaccurate information may hinder the VA's ability to thoroughly research military records and supporting evidence for the claim. The responses submitted are confidential, but accuracy is essential for a successful claim.
Is there a penalty for submitting false information?
Yes, the law imposes severe penalties for knowingly submitting false statements or evidence. This can include fines or imprisonment. It is important for veterans to provide truthful information when completing the form.
Where can I get help if I am in crisis?
If you or someone you know is in crisis, immediate help is available. Veterans can call the Veterans Crisis Line at 1-800-273-8255 and press 1, or visit the website to chat online. Confidential support is accessible 24/7.
Common mistakes
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Incomplete Incident Descriptions: Many individuals fail to provide detailed accounts of the stressful incidents. It is essential to describe what happened, including specific dates and locations. Without thorough descriptions, the VA may struggle to validate the claim.
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Neglecting to Identify Additional Sources: Some applicants overlook the importance of mentioning other sources of information. Statements from roommates, family members, or healthcare providers can significantly support a claim. These sources can provide valuable insights into the incident and its aftermath.
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Failure to Sign and Date the Form: A common mistake is not signing or dating the form. The signature is a critical part of the application process. Without it, the form may be considered incomplete and could delay the claim.
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Ignoring Instructions for Clarity: Many people do not follow the instructions to complete the form neatly and legibly. Illegible handwriting can lead to misunderstandings or misinterpretations of the information provided, potentially harming the claim.
Documents used along the form
The VA Form 21-0781A is a critical document used by veterans to support claims for service connection related to post-traumatic stress disorder (PTSD) stemming from personal assault. Alongside this form, several other documents may be necessary to strengthen a claim. Below is a list of commonly used forms and documents that veterans might need to submit.
- VA Form 21-4142: This form, titled "Authorization and Consent to Release Information to the Department of Veterans Affairs," allows veterans to authorize healthcare providers to release medical records related to their claim.
- VA Form 21-526EZ: Known as the "Application for Disability Compensation and Related Compensation Benefits," this form is used to apply for disability compensation based on service-related injuries or conditions.
- VA Form 21-0781: Similar to the 21-0781A, this form is a "Statement in Support of Claim for Service Connection for PTSD," but it is used for claims not specifically related to personal assault.
- VA Form 21-527EZ: This is the "Application for Pension," which veterans use to apply for pension benefits based on financial need and wartime service.
- VA Form 21-0958: The "Notice of Disagreement" form is used to appeal a decision made by the VA regarding a claim for benefits.
- VA Form 21-0781B: This form is a "Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Assault," which can help provide additional context or detail about the incident.
- VA Form 21-0845: This form, "Authorization to Disclose Personal Information to a Third Party," allows veterans to authorize someone else to receive information about their claims.
- Buddy Statements: These are personal statements from fellow service members or family members who can provide insight into the veteran's experiences and behaviors following the stressful incident.
- Medical Records: Documentation from healthcare providers that detail the diagnosis and treatment of PTSD or related conditions can significantly support a claim.
- Personal Journals or Diaries: These can provide a first-hand account of the veteran's experiences and emotional state following the incidents in question.
Each of these documents plays a vital role in substantiating a veteran's claim. Collectively, they provide a comprehensive view of the veteran's experiences, medical history, and the impact of their service on their mental health. Properly completing and submitting these forms can greatly enhance the chances of a successful claim outcome.
Similar forms
The VA Form 21-0781 is similar to the VA Form 21-4138, which is a Statement in Support of Claim. Both forms are used by veterans to provide additional information that supports their claims for benefits. While the 21-0781 focuses specifically on incidents related to post-traumatic stress disorder (PTSD) stemming from personal assault, the 21-4138 allows veterans to provide a broader range of information regarding their claims. Veterans can use the 21-4138 to describe any aspect of their service that they believe warrants consideration, making it a versatile tool in the claims process.
Another document that resembles the VA Form 21-0781 is the VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs. This form is crucial for veterans who need to share medical records or other sensitive information from third-party providers. While the 21-0781 captures the veteran's narrative and specific incidents leading to PTSD, the 21-4142 focuses on obtaining necessary documentation from other sources. Together, these forms help ensure that the VA has a complete understanding of the veteran's circumstances and health history.
The VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, is another important document. This form serves as the primary application for disability benefits, including those related to PTSD. While the 21-0781 provides detailed accounts of specific incidents that may have led to the condition, the 21-526EZ is where veterans formally request compensation. The two forms complement each other, as the information from the 21-0781 can strengthen the claims made in the 21-526EZ.
Similar to the VA Form 21-0781 is the VA Form 21-0845, Authorization to Disclose Personal Information to a Third Party. This document allows veterans to authorize someone else to receive information about their claim or benefits. While the 21-0781 focuses on the veteran's personal experiences, the 21-0845 is about communication and information sharing. This form is particularly useful for veterans who may want a family member or advocate to assist them throughout the claims process.
The VA Form 21-0958, Notice of Disagreement, also shares similarities with the VA Form 21-0781. This form is used when a veteran disagrees with a decision made by the VA regarding their claim. While the 21-0781 is about providing evidence to support a claim, the 21-0958 is about contesting a decision. Both forms are integral to the claims process, allowing veterans to navigate their rights and seek the benefits they deserve.
Lastly, the VA Form 21-0770, Request for Information, can be seen as related to the VA Form 21-0781. This form is used when veterans need to request specific information from the VA regarding their claims. While the 21-0781 provides a narrative of experiences that support a claim, the 21-0770 is a proactive step for veterans seeking clarity on their claims status or additional information. Both forms emphasize the importance of communication and thorough documentation in the claims process.
Dos and Don'ts
Things to Do:
- Complete the form with accurate and detailed information about the stressful incidents.
- Print legibly in ink to ensure clarity and ease of processing.
- Attach additional sheets if more space is needed, clearly indicating which item numbers the information pertains to.
- Include any other sources of information that may support your claim.
- Review the form thoroughly before submission to ensure all sections are completed.
Things Not to Do:
- Do not leave any sections blank; incomplete forms may delay processing.
- Avoid using abbreviations or unclear language that could lead to misunderstandings.
- Do not forget to sign and date the form before submitting it.
- Do not provide false or misleading information, as this can result in serious penalties.
- Do not ignore the importance of including specific dates and locations related to the incidents.
Misconceptions
Understanding the VA Form 21-0781A is crucial for veterans seeking support for PTSD claims. However, several misconceptions can lead to confusion. Here are eight common misunderstandings:
- The form is only for veterans with combat experience. Many believe that only those who have served in combat can file this form. In reality, it is intended for any veteran who has experienced personal assault, regardless of the context.
- Completing the form is optional. Some think that filling out this form is merely a suggestion. However, it is a necessary step for veterans seeking to establish a service connection for PTSD related to personal assault.
- All incidents must be reported in detail. While detailed descriptions are encouraged, it is important to note that veterans can provide as much information as they have. If details are unclear, veterans should still submit what they can.
- Only medical evidence is required. Many assume that only medical documentation is needed to support a claim. In fact, personal accounts, witness statements, and other evidence can be equally important in establishing the claim.
- The form must be completed online. Some believe that the form can only be filled out digitally. Veterans have the option to complete it by hand as well, as long as it is legible.
- Submitting the form guarantees approval. There is a misconception that completing the form will automatically lead to a successful claim. Approval depends on the overall evidence and circumstances surrounding the case.
- Help is not available for filling out the form. Some veterans think they must navigate the process alone. In reality, assistance is available through various organizations and resources dedicated to helping veterans.
- Once submitted, the form cannot be changed. Many believe that after sending the form, no changes can be made. However, veterans can submit additional information or corrections if needed.
Being informed about these misconceptions can help veterans navigate the claims process more effectively. Understanding the purpose and requirements of the VA Form 21-0781A is essential for ensuring that claims are properly supported.
Key takeaways
Key Takeaways for Filling Out VA Form 21-0781A
- Provide detailed descriptions of each stressful incident, including dates and locations.
- List your unit assignment during the incidents to help verify your claims.
- Include any other sources of information, such as treatment providers or personal contacts, to support your claim.
- Use clear and legible handwriting if completing the form by hand, or fill it out online for better clarity.
- Attach additional sheets if more space is needed, clearly indicating which item numbers your responses apply to.
- Ensure your responses are accurate, as incomplete or incorrect information may delay the processing of your claim.